Pastoralist health care in Kenya.

Health care for the Kenyan pastoralist people has serious shortcomings and it must be delivered under difficult circumstances. Often, the most basic requirements cannot be met, due to the limited accessibility of health care provisions to pastoralists. This adds major problems to the daily struggle for life, caused by bad climatic circumstances, illiteracy and poverty. We argue that strong, integrated and community based primary health care could provide an alternative for these inadequacies in the health system. The question then is how primary health care, which integrates a diversity of basic care provisions, such as pharmaceutical provision, child delivery assistance, mother and childcare and prevention activities, can be implemented. In our view, an appropriate mix of decentralisation forms, warranting better conditions on the one hand and relying on the current community and power structures and culture on the other hand, would be the best solution for the time being.

Understanding the feasibility of integrated care: a rival viewpoint on the influence of actions and the institutional context.

There is in Europe growing awareness that the delivery of integrated care is required to meet the demands of an increasing number of patients with multiple problems. It is also clear that the provision of integrated care is difficult to achieve. As yet, the debate about the circumstances enabling or hindering provision is not settled. The objective of this article is to generate more knowledge on this issue. It is often assumed that the feasibility of integrated care provision is caused by characteristics of the legislation, the financing system and other aspects of the institutional context. Here it is argued that these characteristics are relevant but not decisive. Based on empirical evidence from the Dutch case a rival viewpoint is presented, suggesting that it is the commitment of the actors involved, their support, and the way developments are being managed, that make the difference. Following presentation of the evidence, the implications of the findings for integrated care policy are discussed.

Integrated care management: applying control theory to networks.

Delivery of integrated care by interorganizational networks attracts much attention in Europe. Such care is required to meet the demands of multi-problem patients. Many efforts are made to establish networks. Often, established networks do not deliver integrated care. Managers must understand the background of this problem, in order to deal with it. The issue addressed here concerns behaviour control in networks of autonomous care-providing organizations. So far, publications have focused on behaviour control in single organisations. Based on empirical data we argue that, due to an essential distinction between networks and single organizations, behaviour control in the former should be approached differently. In addition, we discuss the implications of our findings for the management of integrated care delivery.

Integrated care: the impact of governmental behaviour on collaborative networks.

Integration of care is necessary to secure the most appropriate match of the individual demands and the organisational and professional supply. Although this is a basic assumption of all the people involved in health and social care, the magnitude and persistence of obstacles to integration is a common problem in most European countries. In this article, we will explore the role of the Dutch government in the complex interplay of forces around the development of integrated care, within networks of collaborating health and social care agencies. By analysing the behaviour of the Dutch government, we will argue that, in principle, the authorities can play a facilitating role here. For several reasons, however, the government appears not to be able to adequately stimulate the establishment of integrated care arrangements. Examples of such ineffective governmental behaviour are measures with contradictory effects and the adoption of a traditional public finance perspective of comprehensive planning. Our conclusion is that, where local networks play a dominant role in integrated care delivery, the most effective governmental steering should be tailored steering, including a mix of specific steering measures suitable to specific local circumstances, combined with more general steering measures, like financial stimuli, based on legislation.

Home care policy in the Netherlands. Reforming legislation to facilitate the provision of multi-disciplinary home care.

In the Netherlands, it is considered necessary to provide multidisciplinary home care to meet the demands of a growing number of patients. Existing legislation must be changed to facilitate the provision of such care. Although this has been an important government policy goal for several years, it has been extremely difficult to fundamentally change legislation. This article presents an analysis of the Dutch system of decision-making on government policy, to explain why this is the case. Using theoretical concepts such as 'interdependence' and 'steering', the authors studied empirical data published by the Willems Subcommittee, a governmental advisory body.

Inter-organizational networks on the Dutch home health care market.

The demand for home care in the Netherlands is growing and changing. A decreasing rate of institutionalization, combined with an increasing number of elderly people with special age-related, often complex health problems, has led to new groups of patients, to be cared for in their home settings. This requires a strong coordination of services between suppliers from the primary and secondary health care sectors. In order to promote coordinated care, Dutch health care providers are building inter-organizational networks. The development of such arrangements was the target of 12 demonstration projects, selected by the Ministry of Health for the National Home Care Programme. This article presents some of the results of an evaluation study of the Programme, with special attention given to the question of the extent to which such inter-organizational networks contribute to the balance between quality and cost.

Dutch home care: towards a new organization?

As in all western countries the demand for home care in the Netherlands is rapidly growing. Reduced institutionalization in hospitals and nursing homes, combined with an increasing number of elderly people, have led to new groups of patients, with complex and diverse problems, to be cared for in their home settings. To meet this new demand, it is argued, comprehensive home care arrangements are needed. Development of such arrangements was the target of 12 demonstration projects that were part of the 'National Home Health Care Programme'. This article presents the results of an evaluation study of the Programme, with special attention to factors favouring the development of comprehensive home care arrangements and its effectiveness.

Comparison of the new beta-adrenoceptor antagonist, nadolol, and propranolol in the treatment of angina pectoris.

A randomized, double-blind study was carried out in 24 patients with stable angina pectoris to compare the efficacy of nadolol, a new beta-adrenoceptor antagonist, and propranolol. After a period on placebo, 14 patients received nadolol once daily and 10 patients propranolol 4-times daily over a 10-week dose-ranging period followed by a maintenance period of 4 weeks. Optimal daily dosage for nadolol was 100 mg, and 112 mg for propranolol. Parameters used for evaluation of therapeutic effects included the number of anginal attacks, number of nitroglycerine tablets needed, time before onset of chest pain during exercise test, exercise time, and overall clinical impression of response. The results indicated that nadolol given once daily was equally as effective as propranolol 4-times daily in treating angina pectoris.